Introduction

Stroke risk increases with age and about 75% of stroke patients are those who are 65 years old and above (J Neurosci Nurs, 1994).

It has been reported that stroke patients have an increased malnutrition rate from 16% at admission to 22%-35% after 2 weeks in the ward (Acta Med Scand, 1988). This condition worsens once patients are discharged and returned home, mainly due to sup-optimal nutrition care and usually diet plan that is not tailored to individual needs.

Signs and symptoms

It has been estimated about 29 to 64% of stroke patients would be experiencing dysphagia. Dysphagia is the medical term for the symptom of difficulty in swallowing drinks and food.

Complications

Dysphagia can cause insufficient food intake, leading to weight loss and results in malnutrition. Dysphagiais also associated with dehydration, aspiration and pneumonia (J Neurosci Nurs, 1994).

Dietary management

There are 2 most common dietary interventions for stroke patients with dysphagia:

A. Oral food intake

Swallowing test should be done by a Speech Therapist to determine types of drinks and consistency of food that are suitable to be taken orally by stroke patients. Patient with dysphagia need appropriate individual nutritional management according to patient’s ability to eat, drink and tolerable food texture.

Texture and concentration of the food can be modified by:

1. Mincing foods
2. Grinding / blenderising food (rough)
3. Pureeing foods
4. Thickening foods and drinks using thickening agents such as : corn flour or commercial products.

Diagram 1: Minced diet

Rajah 2: Grinded / Blenderised diet

Diagram 3: Pureed diet. Example: Mashed potato

Diagram 4: Thickened foods / drinks with thickening agents

B. Example of Porridge Recipes
No need to blenderise or strain the dish if the patient is able to swallow soft food.

Anchovy’s Porridge (Bubur Ikan Bilis)
(223 calories, 12 g protein)

Ingredients:

1. ¼ cup of rice
2. 3 tablespoon anchovies
3. ¼ teaspoon salt – optional
4. ¼ cup of carrots (diced small) or other vegetables
5. 1 shallot
6. 1 garlic
7. 1 tablespoon oil

Method:

1. Cook rice with 1 cup of water until it becomes porridge.
2. Saute red onions, garlic and anchovies.
3. Boil carrots or other vegetables until soft.
4. Add sauted onion, garlic, anchovies and carrot into porridge and add salt
5. Blend porridge until become it become liquid – then strain.
6. Add ¼ cup water if the porridge is too thick & concentrated.

Chicken / Fish Porridge
(205-211 calories, 7-10g protein)

Ingredients:

1. ¼ cup of rice
2. ¼ cup of chicken/mackerel (without bones)
3. ¼ teaspoon salt
4. ¼ cup of carrots or other vegetables
5. ¼ mug of peas
6. 1 tablespoon oil

Method:

1. Cook rice with 1 cup water until it becomes porridge.
2. Boil and mince fish/chicken.
3. Boil carrots and peas until soft.
4. Saute chicken / fish, carrots and peas and pour into porridge
5. Add salt and mix them well.
6. Blend porridge until it becomes liquid – then strain.
7. Add ¼ cup water if the porridge is too thick & concentrated.

Bread Porridge
(190kcal, 11g protein)

Ingredients:

1. 2 slices of bread
2. 200 ml low fat milk

Method:

1. Blend bread with milk until they become liquid and strain.
2. Get 250 ml of measurement for the porridge.

C. Feeding through Enteral feeding tube

For those patients who are unable to eat and drink orally and of high risk for aspiration, they need to be fed using enteral feeding tube until they are able to swallow normally. Some severe stroke patients might need enteral nutrition support via tubes permanently.

The feeding route and the diet type through thetube are planned by the professionals from hospital or clinic. However, family members need to choose suitable products to be given at home.
For stroke patients with good functional gastrointestin, the enteral polymeric formula would be a better choice. Polymeric formulas contain intact carbohydrate, protein and fat and need to be digested. There are a variety of enteral polymeric formulas in the market and available at pharmacies, Chinese herbal shops, drugstores and supermarkets.

There are also polymeric formulas high in fibre, protein and energy to accommodate the individual need of the patient. Specialised enteral products formulated for certain condition are available too. Homemade formulas with skim milk, low fat milk, or full cream milk with added fine cereals can also be given via enteral feeding tube as advised by a dietitian.
Often, 1200 – 1800 ml of enteral formula with standard dilution would be able to meet the nutrient requirement for most patients. It is compulsory for patient or family members to seek dietary advice from a nearby hospital or clinic dietitian before taking enteral formula or homemade formulas. The dietitian can help to plan feeding regime; inclusive of type of formula, dilution, amount and timing.

Family members who wish to feed blenderized food through the enteral feeding tube should get guidance from a dietitian. However, the nutrient composition of blenderized diet is low and inaccurate. The concentration can differ between preparation and expose patient to higher risk of contamination. Tube clogging is a common problem with such diet. Extra caution has to be taken by care giver and always approach health care professionals for advice.

References

1. Lugger KE. Dysphagia in the elderly stroke patient. J Neurosci Nurs1994
2. Avelsson K, Asplund K, Norberg A, Alafuzoff I. Nutritional status in patients with acute stroke. Acta Med Scand 1988
3. Mann G, Hankey GJ, Cameron D. Swallowing function after stroke: progress and prognostic factors at 6 months. Stroke 1999
4. Hillel M. Rehabilitation medicine: 2. Diagnosis of dysphagia and its nutritional management for stroke patients. CMAJ 2003